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Based on interview and record review, the Hospital failed to:

1. Ensure the Emergency Department (ED) log information was correct and complete to include patients' arrival, treatment, and disposition.

2. Monitor the compliance by observation and chart review as written in the hospital ' s plan of correction.

These failures of inaccurate tracking of the patients ED course, disposition, and need for follow-up had the potential to cause delay of treatment.

Findings:

The hospital's Plan of Correction (POC) with a completion date of 4/4/14 read:

"KMC has reviewed and revised its ED log to ensure the hospital maintains the necessary information for each individual who comes to the ED seeking assistance. KMC has worked with the Information Systems department to ensure that all required items populate when the electronic ED log is printed. Responsible person(s): Clinical Director and Supervisor of Emergency Department, Chief Nursing Officer... All staff currently working have received education related to the following: (1) The need to greet each person and determine if they are a visitor or patient; (2) The need to complete a Quick ID form containing patient's name, date of birth, chief complaint, sex, date and time, and initials; (3) Requirement for all patients to be registered to ensure the patient is placed in the ED log; (4) Requirement to offer every patient a medical screening examination..." And
"The Clinical Director/Supervisor or their designee will complete random observation audits on day shift (7:00 AM to 7:00 PM) and night shift (7:00 PM to 7:00 AM) which will include the following: (1) Observation-Nurse greets person and determines if person is visitor or patient. Nurse completes Quick ID form. Nurse takes Quick ID form to registration. Nurse offers medical screening examination to patient. Nurse requests patient to wait to be seen or walks patient to cubical, if available. (2) Chart audit-Completed Quick Registration is present in chart. Medical screening is present and complete."

During a record review on 4/8/14, the ED log was reviewed. The log indicated the following:

Patient 1 arrived at the ED on 4/4/14, at 1:49 AM. There was no discharge date, discharge time, or disposition documented. Patient 1 was currently an in-patient in the hospital.

Patient 2 arrived at the ED on 4/4/14, at 6:42 AM. There was no discharge date, discharge time, or disposition documented. The Quick ID Form had no legible time documented. The ED Nursing Rapid Triage indicated Patient 2 arrived at the ED at 7:08 AM, a 26-minute discrepancy.

Patient 3 arrived at the ED on 4/4/14, at 8:23 PM. The Quick ID Form had no legible time documented.

Patient 4 arrived at the ED on 4/5/14, at 10:07 AM. There was no discharge date, discharge time, or disposition documented. The Quick ID Form had no legible time documented. Patient 4 was currently an in-patient in the hospital.

Patient 6 arrived at the ED on 4/4/15, at 9:33 AM. The ED Nursing Rapid Triage indicated Patient 6 arrived at the ED at 9:35 AM, a 2-minute discrepancy. Patient 6's vital signs were documented as taken at 9:30 AM (3 minutes prior to his arrival at the ED).

Patient 7 arrived at the ED on 4/4/14, at 9:52 AM. The Quick ID Form had no legible time documented.

Patient 8 arrived at the ED on 4/4/14, at 10:02 AM. The Quick ID Form had no legible time documented.

Patient 9 arrived at the ED on 4/4/14, at 10:23 AM. There was no discharge date, discharge time, or disposition documented. The Quick ID Form had no legible time documented.

Patient 10 arrived at the ED on 4/3/14, at 3:56 PM. There was no discharge date, discharge time, or disposition documented.

Patient 11 arrived at the ED on 4/4/14, at 1:39 PM. There was no discharge date, discharge time, or disposition documented. The ED Nursing Rapid Triage indicated Patient 11 arrived at the ED at 1:45 PM, a 6-minute discrepancy.

Patient 12 arrived at the ED on 4/4/14, at 4:53 PM. There was no entry of mode of arrival, discharge date, discharge time, or disposition. The Quick ID Form had no legible time documented.

Patient 13 arrived at the ED on 4/4/14, at 8:57 PM. The Quick ID Form had no legible time documented.

Patient 14 arrived at the ED on 4/4/14, at 9:04 PM. The log did not have discharge date, discharge time, or disposition documented.

Patient 15 arrived at the ED on 4/5/14, at 9:51 AM. There was no discharge date, discharge time, or disposition documented. The handwritten Critical Nursing Record indicated Patient 15 arrived at 10 AM, a discrepancy of 9-minutes.

The "ED NSG (Emergency Department Nursing) Rapid Triage" indicated Patient 17 arrived at the ED on 4/5/14 at 3:43 PM. The ED log indicated Patient 17 arrived at 3:43 PM. There was no documentation of the patient ' s departure time, disposition, or arrival mode.

Patient 21 arrived at the ED at 2:30 PM on 4/5/14 according to the "Quick ID Form." The document titled "ED NSG Rapid Triage" indicated Patient 21 arrived at the ED on 4/5/14, at 2:52 PM, a 22-minute discrepancy.

The "Quick ID Form" indicated Patient 24 arrived at the ED at 2:58 PM on 4/5/14. The document titled "ED NSG Rapid Triage" indicated Patient 24 arrived at the ED on 4/5/14, at 3:06 PM. But a physician saw the patient at 3:05 PM, one minute before the patient was triaged.

The "Quick ID Form" indicated Patient 28 arrived at the ED on 4/6/14, at 10:02 PM. The "ED NSG Rapid Triage" did not have Patient 28 ' s arrival time, but did indicate a physician was at bedside examining him at 9:30 PM, 32 minutes before the patient arrived the ED.

During a concurrent interview and review of the above ED clinical records with a registered nurse (RN 13) on 4/9/14, RN 13 verified the above findings. RN 13 stated the ED logs should contain the correct information about the patients' visits to the ED.

2. On 4/8/14, the "EMTALA Emergency Audit" dated 4/5/14 was reviewed. The hospital had designated a Medical Support Technician (MST) 1 and a Nurse Assistant (NA) 1 to do the observation audit and the chart audit. During the review, it was identified that seven of 37 records (Patient 6, 32, 7, 33, 9, 34, 8, 35, 36, and 37) showed these patients were seen in the ED on 4/4/14, not 4/5/14.

During an interview on 4/8/14, at 10:40 AM, MST 1 stated she did the chart audits "yesterday" (4/7/14).

During an interview on 4/8/14, at 10:50 AM, NA 1 stated she did her observations on "Friday" (4/4/14) but did not write the dates on the form. She stated the ED Director 1 had filled in the dates.

During an interview with RN 11 on 4/8/14, at 4 PM, RN 11 stated ED Registration uses the date from the Quick ID Form for the ED log and the patients' medical records. She reviewed some of the Quick ID Forms and agreed the dates were illegible.



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